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STRESS AND STRUGGLES
THE COMPREHENSIVE BOOK ON
STRESS, MENTAL HEALTH AND
MENTAL ILLNESS

Editors
Bettahalasoor S Somashekar
Narayana Manjunatha
Santosh K Chaturvedi

Associate Editors
Yamini Devendran
Shalini S Naik

Foreword by
Dr Afzal Javed
President, World Psychiatric Association

First Edition 2021

Indo-UK Stress & Mental Health Group

The rights of Dr Bettahalasoor S Somashekar, Dr Narayana Manjunatha and Professor
Santosh K Chaturvedi as editors and Dr Yamini Devendran and Shalini S Naik as Associate
editors has been asserted by them in accordance with the prevailing copyright rules and
regulations of India.

The authors are solely responsible for the content of their chapters.
Editorial team is not responsible for content,or opinion of any chapters in this textbook.
All the chapters have been peer reviewed.
The book has been written in Indian English.

All rights are reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means such as electronic, mechanical,
photocopying, recording or otherwise without prior permission of editors and publishers.

Single copies can be made for academic, research or teaching purposes.

First Edition: January 2021

Published by Indo-UK Stress and Mental Health Group, Coventary, UK; Bengaluru, India

ISBN: 9798570115774

Disclaimers
Medical sciences are not precise, and medical knowledge is constantly changing with
addition of new findings and discoveries from research opinion differ. The views expressed
in the book are those of the authors and not necessarily shared by editors. The editors are
not responsible for the content and source of the articles. Readers are advised to consult the
latest information about treatments including pharmacological, psychosocial and alternative
therapies and to be guided by their local guidelines. It is the responsibility of the practitioner
to exercise judgement regarding treatments they provide to their patients. Neither the
publishers, nor the editors are responsible or liable for any damage caused to an individual,
organisation or property from the publication

For feedback, suggestions and enquiries, please contact the Editors. Email address can be
found in their chapters.

ii
 FOREWORD

Professionals have always been discussing the topic of stress and its impact
on well-being. Stress is a common experience, and most people manage without
experiencing serious health problems. However, if stress is overwhelming or
chronic it can affect both physical and mental health. Stress is a complex subject
due to varied meaning, lack of uniform application of stress concepts such as
definition and measurement.  The association of stress and mental illness is well
known, and psychiatric literature provides information about different dimensions
of stress.

This book is a notable addition to the literature on this topic. This book consists
of multiple chapters covering several aspects of stress including biological,
psychological, and social issues with a focus on specific stress related disorders,
relations of stress to different psychiatric disorders and general management
principles. Altogether, this book gives an excellent overview of the topic.
Different chapters are highly relevant to the changing global landscape and current
perspectives and can be useful for its relevance to many disciplines.

The authors bring together the basics of stress, and its effect on mental disorders
and on special population as well as management of stress at different levels. The
contributing authors are experienced professionals working in the field of mental
health from several specialities in mental health. They are having either special
interest in stress and stress related disorders or are involved in teaching and training
programmes on this issue. It is relevant for all health professionals in general and
for mental health professionals in specific because of its relevance to mental health.

Although the primary targets of the book may be higher trainees and
postgraduate students in psychiatry and allied mental health specialities, it is
expected that professionals from other disciplines, including clinical psychology,
social work and psychiatric nursing will also find this book highly valuable. This
is also a useful book for practicing psychiatrists and specialists of other medical
disciplines. The other important groups who would benefit may include researchers,
academicians, and health policies planners.

iii
 Editors of this book, Bettahalasoor Somashekar, Narayana Manjunatha and
Santosh Kumar Chaturvedi are well acclaimed and much-admired clinicians,
researchers and teachers and I would wish that this book will have a significant
national, regional & international audience.

Dr Afzal Javed
President
World Psychiatric Association

WPA Secretariat
Geneva University Psychiatric Hospital
2 chemin du Petit-Bel-Air
1226 Thônex / Geneva, Switzerland
Email : afzalj@gmail.com
Web: www.wpanet.org

iv
 PREFACE

This book is a response to curiosity of trainees and medical students. The

current generation of trainees are inquisitive, articulate and expect precise answers.
Stress is one among the several topics on which they are seeking clarity. This
is understandable as the literature on the stress is unclear, ambiguous and filled
with individualistic views. The common resources trainees and medical students
approach usually make an oblique reference to stress and switch to describing
either causes or management of stress without addressing the fundamental issue
about what stress is. In addition, the literature links stressors as aetiology of mental
illnesses without definitive evidence leading to confusion about management of
mental illness such as rationale for treatment of mental illness with drugs.

The following are some common questions professionals and trainees are
looking for answers

What is stress?
How is it assessed and measured?
Does stress cause mental illnesses?
Can people develop mental illness without stress or stressors?
Can stress be managed and prevented?

And so on

It is challenging to answer the above questions precisely because most

literature makes a reference on stress for almost all psychiatric disorders in a
general sense without rationale or evidence to answer genuine doubts. Despite
claims of stress being important, we did not find clinically agreed approach to
understand its relationship with mental illness. In addition, there is no single
source where all aspects of stress in relation to mental illness are available. We
compiled a brief summary on stress and its relation to mental illness for teaching
purposes and approached colleagues interested in teaching and research to help us
out. The request was responded with such a spirit that the initial intention to make

v
a brief overview has turned into a comprehensive textbook containing more than
600 pages. More than 80 colleagues involved in teaching, research and interested
in stress across the world have contributed to bring together several aspects of
stress in one book. The content of each chapter is a distilled product of authors
analysis on a specific aspect of stress from a sea of literature. Although the content
of each chapter is comprehensive on its own, our primary aim to provide coherent
understating of stress and its relationship to mental disorders has been retained. We
did not intend to provide exhaustive review of literature however the content of
each chapter provides valuable information and current trends.

The research on stress and mental illness has centred around the life events
and expressed emotions. Psychological understanding of and research on stress
has largely been limited to ‘fight and flight’ response. People under stress respond
in many ways than just fight or flight, they may choose to ignore, deny, freeze,
and see as an opportunity. Studying on the different response would provide better
understanding effects of stress on person life, give new insights to their coping
abilities and provide basis to explore avenues in the management of stress.

The book is organised by arbitrarily dividing the content into 5 parts covering
specific aspects of stress and its relation to mental illnesses for practical reasons.
However, they are not mutually exclusive, and a degree of overlap cannot be
avoided.

Part I of the book provides basics of stress such as evolution of the concept of
stress, meaning and definition, classification, biological and psychological aspect
of stress. Part II to focus on the illnesses caused by stress such as trauma and
stress related disorders (DSM-5) and disorders associated with stress (ICD 11). The
focus of Part III of the book is on the relationship between stress and individual
psychiatric disorders. Part IV focuses on the stress and specific populations.
Finally, Part V of the book covers broad strategies on management of stress.

The book can be used several ways. Firstly, reader can have a comprehensive
understanding of stress and its relation to mental disorders by reading through all
parts. Secondly, each part of the book covers specific aspect of stress and the reader
may choose a part of the book in which they are interested. Thirdly, wide range of
topics on stress and its relation to mental disorders are covered and hence the book

vi
can be used as a reference on a topic of choice by glancing the contents. Finally,
although reader can choose any chapter, we would recommend medical students
and postgraduate trainees to read part one to begin with as this section provides
basics on stress and acts as foundation to grasp broader aspects of stress.

We hope that the book is helpful for postgraduate trainees in psychiatry,

medicine, clinical psychology, social work and psychiatric nursing on several
aspects of stress and its relation to mental illnesses. The book is also useful for
psychiatrist and medical disciplines that come across patients with stress related
disorders. In addition, researches, academicians and policy makers who are
interested in stress and related disorders would find the book useful.

Bettahalasoor Somashekar
Narayana Manjunatha
Santosh K Chaturvedi

vii
viii
 Acknowledgements

It has been a long journey from the conception of the idea of book 5 years
ago to this final product. The lessons learnt in the process of achieving the feat
was the importance of teamwork, convergence of intention and action, enthusiasm
and persistence. Mere intention without action and teamwork results in distress.
Teamwork with enthusiasm and common goal makes the stress positive, and
fulfilling.

Several people directly and indirectly have contributed to accomplish the task.
First and foremost, we are deeply grateful to all the authors for their exemplary
contributions. The authors have spent time and energy outside of their routine work
to write the chapters only on our request.

We would like to thank Dr Afzal Javed, President, World Psychiatric

Association, for his constant encouragement, and for writing the Foreword.

We would like to thank Dr Sharon Binyon, Medical Director, Coventry and

Warwickshire Partnership NHS Trust Coventry, UK for her encouragement to seek
excellence and support academic activities; Dr Ashok Kumar Jainer Consultant
Psychiatrist for his support to keep our enthusiasm not to fade at different stages in
the development of book.

We would like to thank Dr Supriya Dastidar, Higher Specialist Trainee in

Psychiatry for the poem and her son Anurag Dastidar for his drawings.

We thank Dr Yamini D for contributing few of her sketches to this book that
has helped us to enhance the aesthetics further.

We would like to thank Aditi Printers for designing, formatting and printing
the book.

Finally, we would like to thank our medical students and postgraduate trainees
for stimulating and keeping us interested in the topic of stress and teaching.

ix
 We would like to thank profusely, the artists who created the cover design and
the pictures the book.

Dr. Vijetha J. has completed her MBBS from Bangalore Medical

College and Research Institute, Bangalore. She pursued DNB
in Radiation Oncology at HCG Bangalore Institute of Oncology.
She has a total of seven years of post PG experience in the field
of Oncology and is currently working at CYTECARE CANCER
HOSPITALS, Bangalore. She has keen interest in paintings and sketches and her
artwork has adorned the various sections of this book as well as the cover page.

Mr. Rohin. B. Shivaprakash, is a 2nd year MBBS student from

Bangalore Medical College and Research Institute, Bangalore.
His favourite subjects include Physiology, Pharmacology and
Pathology. He is also a national level swimmer who has represented
state and the university in several national competitions. He is a
recent entrant into the field of digital art and design and has helped design the front
cover of the book.

x
 Table of Contents

Part I BASICS OF STRESS 1

1 Introduction to Stress and Mental Illness 3

Bettahalasoor Somashekar, Narayana Manjunatha, Santosh
Kumar Chaturvedi
2 Conceptual Issues of Stress 15
Bettahalasoor Somashekar, Shahnaz Hassan,
Balaji Wuntakal
3 Biological Effects of Stress 41
Dhanvi Mesvani, Nishant Goyal
4 Stress and Coping 63
Fasli KP Sidheek, Veena A Satyanarayana
5 Biomarkers of Resilience 74
Damodharan Dinakaran, Kamaldeep Sadh,
Suresh Bada Math, Ganesan Venkatasubramanian
6 Stress and Accelerated Aging 91
Yamini Devendran

Part II STRESS RELATED DISORDERS 109

7 Stress and Physical Disorders 111

Barikar C Malathesh, Anil Kumar Mysore Nagraj,
Vinutha Ravishankar, Prabhat Kumar Kodancha,
Channaveerachari Naveen Kumar
8 Stress Related and Stress Induced Psychosis 134
Prateek Varshney, Santosh Kumar Chaturvedi
9 Stress and Adjustment Disorder 152
Guru S Gowda, Barikar C Malathesh,
Narayana Manjunatha
10 Stress and Acute Stress Disorder 168
Shalini S Naik, Barikar C Malathesh,
Narayana Manjunatha
11 Stress And Post-traumatic Stress Disorder 183
Nilamadhab Kar

xi
Part III STRESS AND SPECIFIC MENTAL DISORDERS 213

12 Stress and Psychotic Disorders 215

Shyam Sundar Arumugham, Jagadisha Thirthalli
13 Stress and Somatic Symptoms Disorders 235
Abhinav Nahar, Geetha Desai
14 Stress and Depressive Disorders 252
Avinash Sharma
15 Stress and Anxiety Disorders 275
Pavithra Jayasankar, Barikar C Malathesh, Narayana
Manjunatha
16 Stress and Sleep Disorders 296
Kaustav Kundu, Vishal Dhiman, Ravi Gupta
17 Stress and Sexual Disorders 322
Vyjayanthi N Venkataramu, Chethan Basavarajappa
18 Stress and Eating Disorders 333
Balaji Bharadwaj, Shivanand Kattimani
19 Stress and Alcohol Addiction 343
Siddarth Sarkar, Kirti Sharma
20 Stress and Tobacco Addiction 357
Tanmay Joshi, Sharad Philip, Aniruddha Basu
21 Stress and Technology Use 376
Pranjali Chakraborty Thakur, Manoj Kumar Sharma
22 Stress and Personality Disorders 392
Thamilselvan Palanichamy, Manoj Kumar Sharma
23 Stress and Suicide 406
Barikar C Malathesh, Parvathareddy Lakshmi Nirisha,
Suresh Bada Math

Part IV STRESS AND SPECIFIC POPULATION 425

24 Stress Among Women- Causes and Consequences 427

T A Supraja, C Bhargavi, Prabha S Chandra
25 Stress in Children and Adolescents 450
Shivanand Kattimani, Balaji Bharadwaj

xii
 26 Stress and Aging/ Old age 462
Palanimuthu T Sivakumar, Shiva Shanker Reddy Mukku,
Subhashini K Rangarajan
27 Occupational Stress 478
Pappu Srinivasa Reddy, Neeraj Bajaj, Pallavi Nadkarni
28 Stress and Disaster 500
Kamaldeep Sadh, Damodaran Dinakaran,
Channaveerachari Naveen Kumar
29 Stress and Neurodevelopmental Disorders 512
Arul Jayendra Pradeep Velusamy, Lakshmi Sravanti
30 Stress, Caregiver, and Mental Illness 526
Hareesh Angothu, Abhishek Allam, Lokeswara Reddy
Pabbathi
31 Stress and Crime 540
Nellai K Chithra, Barikar C Malathesh, Suresh Bada Math

Part V MANAGEMENT OF STRESS 559

32 Psychopharmacological Management of Stress and 561

Related Disorders
Damodaran Dinakaran, Bettahalasoor Somashekar, Ashok
Kumar Jainer
33 Psychological Treatment of Stress 577
Supriya Dastidar, Bettahalasoor Somashekar, Ashok Kumar
Jainer
34 Traditional Methods of Stress Management 601
Sneha J Karmani, Shivarama Varambally
35 Stress and Psychological First Aid 622
Meena Kolar Sridara Murthy, Anish V Cherian, Latha
Krishnamurthy
36 Stress and Tele-Psychiatry 631
Ravindra Neelakanthappa Munoli, Sivapriya Vaidyanathan

xiii
 Chapter 9

STRESS AND ADJUSTMENT DISORDER

Guru S Gowda, Barikar C Malathesh, Narayana Manjunatha
Department of Psychiatry, National Institute of Mental Health and
Neuro Sciences (NIMHANS), Bengaluru, INDIA

Corresponding Author
Dr N Manjunatha
Tele-Medicine Centre, Department of Psychiatry,
National Institute of Mental Health and Neuro Sciences (NIMHANS)
Bengaluru, INDIA
manjunatha.adc@gmail.com

OUTLINE
1. INTRODUCTION 2. STRESS AND PHENOMENOLOGY IN
ADJUSTMENT DISORDER
3. NOSOLOGY OF ADJUSTMENT 4. EPIDEMIOLOGY
DISORDERS
5. AETIOLOGY: STRESS AND 6. CLINICAL FEATURES
ADJUSTMENT DISORDER
7. DIAGNOSTIC CRITERIA 8. DIFFERENTIAL DIAGNOSIS
9. COMORBIDITY 10. TREATMENT
11. COURSE AND OUTCOME 12. CONCLUSIONS

INTRODUCTION
Historically, Adjustment Disorder (AD) has been viewed as a transitional diagnostic
category and, by definition, it is not an enduring diagnosis. It is presumed that the AD
would not arise without the presence of stressor and symptoms of AD do not persist
beyond six months after the stressor or its consequences have been terminated. The
diagnostic category of AD is used widely among clinicians. AD is also considered
a universally less stigmatizing psychiatric diagnosis among the public (Bourgeois
et al., 2012). AD was introduced in the first edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-I) under the category of “Transient Situational
Personality Disorder”. AD has been a recognised disorder for over a decade. It
has been placed under ‘Trauma and Stressor-Related Disorders’ in DSM -5. The
construct of AD is often criticized for the lack of scientific support, and there are

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 STRESS AND STRUGGLES

very few controlled studies in the literature to date on AD(Carta et al., 2009). In
this chapter we shall review the evolution of the concept of AD, its diagnostic
transition, current understanding, and its management with specific emphasis of
this condition in the context of stress..

STRESS AND PHENOMENOLOGY IN ADJUSTMENT

DISORDER
AD is characterized by emotional or behavioural reaction / symptoms to an
identifiable one or more stressful/psychosocial events (Patra & Sarkar, 2013). The
stressors may be single or multiple; it may involve financial issues, other medical
conditions, life events, or relationship issues. Literally, any event can qualify for a
stressor by current diagnostic criteria.

The symptom complex that develops may involve anxious or depressive

affect or may present with a disturbance of conduct with significant social or
occupational impairment. All in all, the symptoms can be considered clinically
significant by virtue of them either causing impairment in social, occupational,
biological function or by being more than what would normally be expected for the
given stressor. So, AD is considered as a maladaptive reaction to a psychosocial
stressor. The symptom complex must not qualify for another Axis I condition (ICD
-10; DSM -5).

NOSOLOGY OF ADJUSTMENT DISORDERS

Diagnostic and Statistical Manual of Mental Disorders (DSM)
The “Transient Situational Personality Disorder” was introduced in DSM-1
in 1952, which describes the individual vulnerability during stressful situations.
Further, it was subtyped as gross stress reaction, adult situational reaction,
adjustment reaction of infancy, adjustment reaction of childhood, adjustment
reaction of adolescence, and adjustment reaction of late-life(American Psychiatric
Association, 1952). Later it was reconceptualized as “Transient Situational
Disorder” in DSM II, thereby removing the term personality and also the emphasis
of linking the presence of personality factors to the development of AD(American
Psychiatric Association, 1968). In the third edition of DSM, the diagnosis of
transient situational disorder was revoked and was renamed as Adjustment
Disorder. Further, the diagnosis of AD was subtyped based on the predominant
affective symptom complex. These included adjustment disorder with depressed

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STRESS AND STRUGGLES

mood, anxious mood, mixed emotional features, disturbance of conduct, mixed

disturbance of emotions and conduct, work inhibition, withdrawal, and atypical
features (American Psychiatric Association, 1980). Following this, there were no
major theoretical changes leading up to DSM-III-R, except that the duration of the
disorder was restricted to 6 months, with the expectation of a return to baseline
function or establishment of a new steady-state characterized by a more specific
diagnosis. In addition, the subtype of adjustment disorder with physical complaints
was added (American Psychiatric Association, 1987).

Table -1: Nosology of Adjustment Disorder

System Salient feature

DSM I Transient Situational Personality Disorder
DSM II Transient situational disorder
DSM –III Adjustment Disorders
No requirement of severe and unusual stress as criteria, and the
duration of AD was not specified
DSM- There were no major theoretical changes, except that the duration
III-R of the disorder was restricted to 6 months.
Also, the subtype AD with physical complaints was added
DSM –IV Duration of the disorder is coded as acute (less than six months) or
chronic (greater than six months)
DSM-IV- The stressor is identifiable but makes no mention as to what would
TR qualify as a stressor.
DSM-IV-TR describes the onset of symptoms of AD within three
months of a stressor and the resolution of symptoms within six
months of the termination of the stressor
DSM-5 Adjustment disorders are reconceptualized as a heterogeneous
stress-response syndrome.
Adjustment Disorder subtypes have been retained, without any
change
*DSM - Diagnostic and Statistical Manual of Mental Disorders

The most significant change from DSM-III-R to DSM-IV was that the disorder’s
duration was allowed to extend beyond the limit of 6-months imposed in DSM-
III-R. The disorder’s duration was coded as acute (less than six months) or
chronic (greater than six months). The AD subtypes, like mixed emotional

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 STRESS AND STRUGGLES

features, work inhibition, withdrawal, and physical complaints, were eliminated

(American Psychiatric Association, 1994). DSM-IV-TR stated that the stressor was
identifiable but made no mention of what would qualify as a stressor. DSM-IV-TR
described the onset of AD symptoms to occur within three months of the onset of a
stressor and the resolution of symptoms within six months of the termination of the
stressor(American Psychiatric Association, 2000; Katzman & Geppert, 2009). In
DSM-5(American Psychiatric Association, 2013), AD has been reconceptualized
as a heterogeneous stress-response syndrome, rather than a residual category as in
DSM-IV with unchanged subtypes. Table – 1 shows a summary of the Nosology
of DSM.

International Classification of Mental and Behavioral Disorders (ICD)

The Clinical description and diagnostic guidelines of AD in ICD-10 are similar
to the DSM 5 entity in outlining the development of psychological symptoms
following a stressor. However, in ICD-10, the symptoms must appear within one
month of the stressors, instead of the 3-month temporal course of DSM-5. The ICD-
10 criteria share with DSM- 5 the requirement that symptoms must not persist for
longer than six months after termination of stressor. The ICD-10 and DSM-5 differ
in their consideration of chronicity. Whereas on one hand, the DSM-5 requires the
specification of ‘acute’ or ‘chronic’ for all subtypes of adjustment disorders, the
ICD-10 only refers to chronicity if the primary symptoms complex involved is that
of depressed state / depression. From ICD-10 to ICD -11 (beta version), AD has
been moved under the category of ‘Disorders specifically associated with stress’,
and its core symptoms are similar to that of ICD‐10 and DSM‐5, without much
change. However, in ICD -11, AD is defined with more clarity than in ICD-10, as a
maladaptive reaction, which usually emerges within one month of a significant life-
stressor. Two symptoms should constitute it: a) preoccupation with a stressor or
its consequences; b) failure to adapt (Maercker et al., 2013). AD can be diagnosed
only if symptoms do not reach sufficient specificity or severity of other mental
disorders, similar to the DSM-5. The AD definition in ICD-11 gives more clarity,
which facilitates AD measurement and focused treatment developments and
research (Kazlauskas et al., 2018; Maercker & Lorenz, 2018). Table 2 shows a
comparison of ICD 10, 11, and DSM 5.

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STRESS AND STRUGGLES

Table- 2: Comparison between ICD-10, ICD -11 and DSM -5

ICD -11 (beta

System ICD-10 DSM -5
version)
Category Neurotic, Stress- Disorders Trauma and
related, and specifically Stressor-Related
Somatoform associated with Disorders
disorders stress
Stressor Present Present Present
Temporal course Symptoms of AD Symptoms of AD symptoms of AD
with the stressor must appear within must appear within must occur within
one month one month three months
Resolution of AD should not persist for longer than six months
after the removal of the stressor
Acute or chronic Not Present Not Present Present
subtypes
Prolonged Present Present Not Present
depressive reaction
*DSM - Diagnostic and Statistical Manual of Mental Disorders
*ICD - International Classification of Mental and Behavioural Disorders

EPIDEMIOLOGY
There are few epidemiological studies on AD. In India, the National Mental Health
Survey-2016 was undertaken in 12 states across six regions. The prevalence of AD
was around 0.24% as per ICD-10 DCR among 34802 general population of age
18+ years (Gururaj et al., 2016). In European Outcome of Depression International
Network (ODIN) study reported a 1% prevalence of AD in the general population.
The higher prevalence in the ODIN study may due to the conflation of ‘Mild
Depression with Adjustment Disorder’(Casey et al., 2006). AD is reported to be
very common in the primary care settings and has ranged from 11% to 18%(Casey,
2009). AD is also highly prevalent in medical settings like primary care, in a
multisite consortium of teaching hospitals the prevalence was about 12% among
1000 patients (Strain et al., 1998). In two different studies, 50% of Cardiac Surgery
patients (n= 71) (Oxman et al., 1994) and 35% of recurrence of Breast Cancer
patients (n=55) (Okamura et al., 2000), had a diagnosis of Adjustment Disorder.
Another large meta-analysis of 94 interview-based studies on the prevalence of AD
found it to be present in 15.4% of adults with cancer in oncological, haematological,
and palliative-care settings(Mitchell et al., 2011).

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 STRESS AND STRUGGLES

The prevalence of AD was found to be 10% among 11,000 patients using a

DSM-III criteria at Western Psychiatric Institute clinical services. Among children
and adolescents under 18 years of age, over 16 percent had AD, which is higher
than other age groups. In adults, the prevalence of AD among females predominated
over males by approximately 2 to 1, the difference in prevalence of AD between
males and females was not so striking among children and adolescents, even
though females had marginally higher prevalence than males even in this age group
(Bogren et al., 2018).A study from Nepal found that 13.5% patients presenting to
emergency department had clinical diagnosis of AD(Ghimire et al., 2014). The
point prevalence AD was 11.5% of 636 patients from the outpatient psychiatric
clinic in Duhok city of Iran(Yaseen, 2017). Table 3 shows the prevalence of
Adjustment Disorder in different settings.

Table -03: Prevalence of Adjustment Disorder in Different settings

Settings Prevalence
General Population 0.24 to 1%
Primary Care 11% to 18%
General Medical Care 12%
Consultation and Liaison Psychiatry 10% to 35%
Psychiatric Outpatient Clinic 10% to 11.5%
Child & Adolescent Psychiatry Clinic 16%

AETIOLOGY: STRESS AND ADJUSTMENT DISORDER

‘Stress’ is defined as the mental or emotional strain or tension resulting from adverse
or demanding circumstances. There are different types and severity of stressors.
Stress may be a desirable or undesirable type(Paykel et al., 1971). Stressors can
be of two types - eustress and distress. Eustress’ defined as positive, constructive
results of stressful events and stress response (Kupriyanov & Zhdanov, 2014) and
Lazarus considers eustress as a positive cognitive response to a stressor, which
associated with positive feelings and a healthy physical state(Lazarus, 1993). On
the other side, ‘distress,’ which is a negative stress impairs functioning (Selye,
1973). The individual’s response to stress is influenced by multiple factors. such
as age, gender, health or psychiatric comorbidity, education, ethical, political,
religious beliefs, etc. The presence or absence of social support, emotional support,
and economic status are other factors in the family environment that can influence
response to stress (Fabrega et al., 1987; Carta et al., 2009; Kocalevent et al.,

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STRESS AND STRUGGLES

2014). Current knowledge of the association between stressful life experience and
symptom development remains complex. There are few theories that have been
proposed to understand the etiology in the development of AD which are discussed
below.

a) The psychoanalysis theory puts considerable emphasis on the context in

which an event occurs before considering symptom development. The lack of
an attuned response from others to stressors usually involved in AD may lead
to the experience of psychological disruption(Katzman & Geppert, 2009).

b) The psychodynamic theory posits a lack of experience of affect or feeling about

the stressor that generates problems. Individuals who lack the opportunity to
experience the feeling associated with stressors are vulnerable when suddenly
exposed to psychosocial triggers, which leads to a sense of danger, anxiety and
threat. It may turn inwards against self, resulting in symptoms of depression.
Recent literature suggests that development of resilience to stressful events
occurs during childhood that results in successful adaptation. It helps in
positive self-concept, optimism, altruism, active coping style, self-regulation of
emotion, and capacity to convert traumatic helplessness to learned helpfulness
model (Katzman & Geppert, 2009).

c) Biological theorists, McEwen and Stellar(McEwen & Stellar, 1993) coined

the term “Allostatic Load” to denote the neurochemical changes following
repeated stressful experiences and the capacity of the individual to cope
with the same. Allostatic load is understood as “the wear and tear on the
body” that accumulates in individuals exposed to repeated or chronic stress.
This also represents the physiological consequences of chronic exposure
to fluctuating or heightened neural or neuroendocrine responses resulting
from repeated or chronic stress. Hippocampal Pituitary Axis, Corticotrophin
Releasing Hormone, Locus Coeruleus – Norepinephrine, dopamine, oestrogen
activity, lowest quartile of dehydroepiandrosterone (DHEA), neuropeptide
Y, galanin, testosterone, 5HT 1A receptor, and Benzodiazepine receptor will
have the highest index for a psychobiological allostatic load (Charney, 2004).
Repeated exposure to stress leads to changes in multiple neuro-chemicals and
their pathways like Hippocampal Pituitary axis, Corticotrophin Releasing
Hormone, Locus Coeruleus – Norepinephrine, dopamine, estrogen activity,
dehydroepiandrosterone (DHEA), neuropeptide Y, galanin, testosterone, 5HT

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1A receptor, and Benzodiazepine receptor. The detailed discussion of the

above is beyond the scope of this chapter.

CLINICAL FEATURES
Diagnosis of AD requires careful consideration of the coping style of the individual,
specific of the situation in which the symptoms have appeared, and self-perception
of the effect of the stressor. It is characterized by emotional or behavioural symptoms
formed in the context of an established psychosocial stressor/s. AD may occur in
any age group; however, it is reported to be more common among the younger age
group(Katzman & Geppert, 2009; Yaseen, 2017) Studies have identified school
problems as the most frequent precipitant of AD in adolescents whereas in adults,
marital problems are most frequent precipitants. Stressors may be single, multiple,
recurrent, or enduring events. As a result, temporal and causal relationships of
stressor with symptoms is difficult to establish in many cases. The commonest
psychosocial stressor was the physical illnesses, followed by relationship problems
and domestic problems (Yaseen, 2017).

AD with depressive symptoms as the most common type of presentation,

characterized by depressed mood, low self-esteem, suicidal behaviours, increased
motor activity, hyper-vigilance, impulsivity, and substance use. Additional
symptoms may include a feeling of helplessness, self -blame, rejection of help,
suicidal ideation, dysphoria, aggression, downheartedness, unspecific somatic
complaints, loss of appetite, sleep disturbance, pain, phobic symptoms, and
reduced drive. Other symptoms presentations of AD are insomnia, other vegetative
symptoms, social withdrawal through behavioural symptoms and mixed
presentations are seen, and suicidal thoughts /ideation. The manifestations vary
and include depressed mood, anxiety, worry (or a mixture of these), a feeling of
inability to cope, plan, or continue in the present situation, and some degree of
disability in the day to day functioning. The individual may feel liable for dramatic
behavior or outbursts of violence, but these rarely occur.

DIAGNOSTIC CRITERIA
ICD -10(World Health Organisation, 1992)
The diagnosis depends on a careful evaluation of the relationship between (a) form,
content, and severity of symptoms; (b) previous history and personality; and (c)
stressful event, situation, or life crisis. The presence of the third factor should be

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established, and there should be strong, though perhaps presumptive evidence, that
the disorder would not have arisen without it. If the stressor is relatively minor,
or if a temporal connection (less than three months) cannot be demonstrated, the
disorder should be classified elsewhere, according to its presenting features.

The conduct disorders (e.g. aggressive or dissocial behavior) may be an

associated feature, particularly in adolescents. None of the symptoms is of sufficient
severity or prominence in its own right to justify a more specific diagnosis. In
children, regressive phenomena such as return to bed-wetting, babyish speech,
or thumb-sucking are frequently part of the symptom complex. If these features
predominate, F43.23 should be used. The onset is usually within one month of the
occurrence of the stressful event or life change, and the duration of symptoms does
not usually exceed 6 months, except in the case of prolonged depressive reaction
(F43.21). If the symptoms persist beyond this period, the diagnosis should be
changed according to the clinical picture present, and any continuing stress can be
coded by means of one of the Z codes in Chapter XXI of ICD-10.

There should be a significant life change leading to continued unpleasant

circumstances that result in an adjustment disorder. The states of subjective
distress and emotional disturbance, usually interfering with social functioning
and performance, and arising in the period of adaptation to a significant life
change or to the consequences of a stressful life event (including the presence or
possibility of serious physical illness). This aspect of it is discussed in an article
titled “Bereavement without death” (Snow, 2017). The stressor may have affected
the integrity of an individual’s social network (through bereavement or separation
experiences) or the wider system of social supports and values (migration or
refugee status). The stressor may involve only the individual or also his or her
group or community.

DSM – 5 (American Psychiatric Association, 2013)

A. Development of clinically significant emotional or behavioural symptoms in
response to an identifiable psychosocial stressor(s). Symptoms must develop
within three months after the onset of the stressor(s)
B. These symptoms or behaviours are clinically significant as evidenced by
either of the following: (1) Marked distress that is in excess of what would
be expected from exposure to the stressor OR (2) Significant impairment in

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social, occupational, or academic functions.

C. The stress-related disturbance does not meet the criteria for another specific
Axis I disorder and is not merely an exacerbation of a pre-existing Axis I or
Axis II disorder.
D. The symptoms do not represent bereavement (code V62.82).
E. Once the stressor (or its consequences) has terminated, the symptoms do not
persist for more than an additional six months.

Table -04: Subtype of Adjustment Disorder in ICD-10 and DSM -5

ICD- 10 DSM -5
a) AD with Brief depressive reaction a) AD with Depressed Mood
b) AD with Prolonged depressive reaction b) AD with Anxiety
c) AD with Mixed anxiety and depressive c) AD with Mixed Anxiety &
reaction Depressed Mood
d) AD with predominant disturbance of d) AD with Disturbance of Conduct
other emotions.
e) AD with predominant disturbance of e) AD with Mix Disturbance of
conduct. Emotions & Conduct
f) AD with mixed disturbance of emotions f) AD with unspecified
and conduct Both emotional symptoms
and disturbance of conduct are
prominent features.
g) AD with other specified predominant
symptoms
*AD- Adjustment Disorder

DIFFERENTIAL DIAGNOSIS
The identified psychosocial stressor with sub-syndromal symptoms distinguish
AD from other Axis I, Post-Traumatic Stress Disorder, and acute stress disorder
as these have the nature of the stressor better characterized and are accompanied
by a defined constellation of affective and autonomic symptoms. In contrast,
the stressor in adjustment disorder can be of any severity, with a wide range of
possible symptoms. The AD subtypes need to be distinguished from sub-threshold
types of the major mental disorders, the so-called not otherwise specified (NOS)
categories.

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a) Depression: Depression can be diagnosed irrespective of presence or absence

of stressor if the criteria for depression are met.

b) Post-traumatic stress disorder (PTSD) and Acute Stress Disorder (ASD):

the stressor required for PTSD and ASD are described in detail in the criterion
A of the respective diagnostic criteria, this stressor is generally extremely
traumatic event and severe in intensity with specific characteristics which is
not so for the stressor that precipitates AD. The timing and the severity of
the symptoms are also different between AD and PTSD & ASD. AD can be
diagnosed immediately following exposure to stressor and can persist up to 6
months after termination of stressor. In contrast, in ASD cannot be diagnosed
if the symptoms persist beyond one month, and PTSD cannot be diagnosed
within 1 month of exposure to stressor.

c) Personality Disorder: Some personality disorders are vulnerability to stress

and develop symptoms suggestive of adjustment disorder. The detailed
longitudinal history will help us in delineating adjustment disorder from
personality disorder. AD can be diagnosed even in presence of personality
disorder if the stress related disturbance is more than what would be explained
by the maladaptive personality traits. (i.e., Criterion C is met).

d) Normative stress reactions: Many individuals get irritable and angry when
things do not happen as expected by them. The diagnosis of AD should be
made only if the disturbance (e.g., mood, anxiety, or behavior changes) are
more than what is normally expected (which could vary in various cultures) or
if there is significant functional impairment.

COMORBIDITY
The most common psychiatric comorbidity associated with AD is personality
disorders and substance use disorders. AD is associated with greater risk for
completed suicide and suicide attempts. On the other hand, psychological autopsy
of suicide attempter show high rate of AD retrospectively (Marttunen et al., 1994;
Greenberg et al., 1995; Pelkonen et al., 2007).

TREATMENT
AD may have sub-threshold symptomatology across various symptom domains;
thus, there is no single therapeutic management strategy for the condition’s

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heterogeneous clinical nature(Casey, 2009). Treatment of individuals with AD

requires careful consideration of the nature and severity of symptoms, taking
into account the risk factors associated with higher risks, such as poor premorbid
functioning and persistent stressors.

The main aim of treatment is to relieve symptoms and reach a higher degree
of premorbid level of adaptive functioning. Treatment strategies should be tailored
to mitigate the effect of stressors on day-to-day functioning and to enhance
adaptive stress coping mechanisms. The specific treatment interventions that are
considered in individuals with AD includes brief supportive counselling (De Leo,
1989), short interpersonal therapy, cognitive behavioural therapy, psychodynamic
approaches(Maina et al., 2005), and integrative therapy(Lakshmi, 2017) The
study from India on AD shows the integrative approach through psychoeducation,
interpersonal therapy, and cognitive behavioural therapy component was found
effective. It not only helps in the treatment of AD but also improves the quality of
life in personal and marital life (Lakshmi, 2017).

Low-intensity psychological interventions, such as e-mental-health

interventions ( telephone / video conference based) for ADs, can be a successful
solution to addressing high mental-health needs associated with AD , can
potentially overcome barriers, increase access to psychological interventions in
ADs especially in limited mental-health resources in most countries around the
world (Domhardt & Baumeister, 2018; Varker et al., 2019).

There are hardly any systematic clinical trials evaluating the effectiveness of
pharmacological treatments in individuals with AD. The commonly used drugs are
antidepressants and anxiolytics. Selective Serotonin Reuptake Inhibitors (SSRIs)
are useful in treating certain sub-threshold depressive syndromes and can help
certain sub-types of AD. Several studies of prescribing practices by physicians
since the 1980s have shown a substantial rise in prescribing antidepressants
(Olfson et al., 1998). However, it should be stressed that psychosocial methods
remain the mainstay of treatment, with the pharmacological intervention being a
supplementary form of treatment. All antidepressants are effective in the treatment
of AD. None of the antidepressants were found to be more effective or superior to
others in the treatment of adjustment disorder. A study showed that the combination
of two classes of antidepressant was not superior to one class of antidepressant
in the treatment of adjustment disorder (Looney & Gunderson, 1978). There are

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non-SSRI clinical trials in adjustment disorders such as TCA, Trazodone, Ginkgo

Biloba specific extract (Woelk et al., 2007), plant extracts (Euphytose), and specific
extracts of kava-kava (Carta et al., 2009). However, the translation of clinical
research results into real-world clinical practice has not been successful

COURSE AND OUTCOME

The role of age, personality style, social support networks, and comorbid conditions
in influencing the path and outcome of AD has been established. Multiple studies
have shown a reasonably benign course for adults, with a lesser risk of recovery in
adolescents following the initial AD episode. While most adults developed major
depressive disorders and alcohol abuse, adolescents reported a wide variety of
major psychiatric disorders, including schizophrenia, bipolar disorder, personality
disorder (Looney & Gunderson, 1978), substance abuse, and major depressive
disorder (Andreasen & Hoenk, 1982). Prevalence of chronic symptoms and
behavioural problems have been the most significant indicator of poor outcomes
for people with AD who may also have a high risk of suicide. Comorbid diagnosis
of drug abuse and personality disorder predict higher chances of suicidal attempts
and competed suicide (Carta et al., 2009). Five years of a follow-up study of 76
AD patients showed an 82% favourable outcome and 17 % chronic depressive
disorder (Bronisch, 1991). Readmission levels and AD-associated impairment
were substantially lower than those diagnosed with comorbid drug use disorder
(Greenberg et al., 1995) and affective disorder (Jones et al., 2002)..

CONCLUSIONS
Adjustment Disorder is considered a universally less stigmatizing psychiatric
diagnosis among the public. AD is a common psychiatric diagnosis in psychiatric
settings. ICD -11 beta version, AD is defined with more clarity than previous ICD
-10 and DSM -5. It has introduced newer concepts in the diagnosis of AD such
as 1) preoccupation with stressful event and 2) failure to adapt. So, newer AD
diagnostic criteria may provide diverse research findings in future studies and help
to conceptualise the disorder better.

References
American Psychiatric Association (1952) Diagnostic and Statistical Manual of Mental
Disorders. 1st edition. Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (1968) Diagnostic and Statistical Manual of Mental
Disorders. 2nd edition. Washington, DC: American Psychiatric Publishing, Inc.

164
 STRESS AND STRUGGLES

American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental

Disorders. 3rd edition. Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental
Disorders. 3rd, rev edition. Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental
Disorders. 4th edition. Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental
Disorders. 4th, rev edition. Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders. 5th edition. Washington, DC: American Psychiatric Publishing, Inc.
Andreasen, N.C. & Hoenk, P.R. (1982) The predictive value of adjustment disorders: a
follow-up study. The American Journal of Psychiatry. 139 (5), 584–590.
Bogren, M., Brådvik, L., Holmstrand, C., Nöbbelin, L. & Mattisson, C. (2018) Gender
differences in subtypes of depression by first incidence and age of onset: a follow-up
of the Lundby population. European Archives of Psychiatry and Clinical Neuroscience.
268 (2), 179–189.
Bronisch, T. (1991) Adjustment reactions: a long-term prospective and retrospective follow-
up of former patients in a crisis intervention ward. Acta Psychiatrica Scandinavica. 84
(1), 86–93.
Carta, M.G., Balestrieri, M., Murru, A. & Hardoy, M.C. (2009) Adjustment Disorder:
epidemiology, diagnosis and treatment. Clinical Practice and Epidemiology in Mental
Health : CP & EMH. 515.
Casey, P. (2009) Adjustment disorder: epidemiology, diagnosis and treatment. CNS drugs.
23 (11), 927–938.
Casey, P., Maracy, M., Kelly, B.D., Lehtinen, V., Ayuso-Mateos, J.-L., Dalgard, O.S. &
Dowrick, C. (2006) Can adjustment disorder and depressive episode be distinguished?
Results from ODIN. Journal of Affective Disorders. 92 (2–3), 291–297.
Charney, D.S. (2004) Psychobiological mechanisms of resilience and vulnerability:
implications for successful adaptation to extreme stress. The American Journal of
Psychiatry. 161 (2), 195–216.
De Leo, D. (1989) Treatment of adjustment disorders: a comparative evaluation.
Psychological Reports. 64 (1), 51–54.
Domhardt, M. & Baumeister, H. (2018) Psychotherapy of adjustment disorders: Current
state and future directions. The World Journal of Biological Psychiatry, 19 (sup1), S21–
S35.
Fabrega, H., Mezzich, J.E. & Mezzich, A.C. (1987) Adjustment disorder as a marginal or
transitional illness category in DSM-III. Archives of General Psychiatry. 44 (6), 567–
572.
Ghimire, S., Devkota, S., Budhathoki, R., Sapkota, N. & Thakur, A. (2014) Psychiatric
Comorbidities in Patients with Deliberate Self-Harm in a Tertiary Care Center. JNMA;

165
STRESS AND STRUGGLES

Journal of the Nepal Medical Association. 52 (193), 697–701.

Greenberg, W.M., Rosenfeld, D.N. & Ortega, E.A. (1995) Adjustment disorder as an
admission diagnosis. The American Journal of Psychiatry. 152 (3), 459–461.
Gururaj, G., Varghese, M., Benegal, V., Rao, G.N., Pathak, K., Singh, L.K., et al. (2016)
National Mental Health Survey of India, 2015-16. National Institute of Mental Health
and Neuro Sciences, NIMHANS.
Jones, R., Yates, W.R. & Zhou, M.H. (2002) Readmission rates for adjustment disorders:
comparison with other mood disorders. Journal of Affective Disorders. 71 (1–3), 199–
203.
Katzman, J.W. & Geppert, C.M.A. (2009). Adjustment Disorder. In: B J Sadok, Verginia A
Sadok, & Pedro Ruiz (eds.) Kaplan & Sadock’s Comprehensive Textbook of Psychiatry.
9th edition [Online]. Lippincott Williams & Wilkins. pp. 2187–96.
Kazlauskas, E., Zelviene, P., Lorenz, L., Quero, S. & Maercker, A. (2018) A scoping review
of ICD-11 adjustment disorder research. European Journal of Psychotraumatology. 8
(sup7), 1421819.
Kocalevent, R.D., Mierke, A., Danzer, G. & Klapp, B.F. (2014) Adjustment Disorders as
a Stress-Related Disorder: A Longitudinal Study of the Associations among Stress,
Resources, and Mental Health. PLoS ONE. 9 (5), e97303.
Kupriyanov, R. & Zhdanov, R. (2014) The Eustress Concept: Problems and Outlooks. World
Journal of Medical Sciences. 11179–185.
Lakshmi, G.P. (2017) Effectiveness of an Integrative Approach on Adjustment Disorder.
Psychology and Behavioral Science International Journal. 5 (4), 1–7.
Lazarus, R.S. (1993) From Psychological Stress to the Emotions: A History of Changing
Outlooks. Annual Review of Psychology. 44 (1), 1–22.
Looney, J.G. & Gunderson, E.K. (1978) Transient situational disturbances: course and
outcome. The American Journal of Psychiatry. 135 (6), 660–663.
Maercker, A., Brewin, C.R., Bryant, R.A., Cloitre, M., van Ommeren, M., Jones, et al.
(2013) Diagnosis and classification of disorders specifically associated with stress:
proposals for ICD-11. World Psychiatry. 12 (3), 198–206.
Maercker, A. & Lorenz, L. (2018) Adjustment disorder diagnosis: Improving clinical utility.
The World Journal of Biological Psychiatry. 19 (sup1), S3–S13.
Maina, G., Forner, F. & Bogetto, F. (2005) Randomized controlled trial comparing brief
dynamic and supportive therapy with waiting list condition in minor depressive
disorders. Psychotherapy and Psychosomatics. 74 (1), 43–50.
Marttunen, M.J., Aro, H.M., Henriksson, M.M. & Lönnqvist, J.K. (1994) Adolescent
suicides with adjustment disorders or no psychiatric diagnosis. European Child &
Adolescent Psychiatry. 3 (2), 101–110.
McEwen, B.S. & Stellar, E. (1993) Stress and the individual. Mechanisms leading to disease.
Archives of Internal Medicine. 153 (18), 2093–2101.

166
 STRESS AND STRUGGLES

Mitchell, A.J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C. & Meader, N.
(2011) Prevalence of depression, anxiety, and adjustment disorder in oncological,
haematological, and palliative-care settings: a meta-analysis of 94 interview-based
studies. The Lancet. Oncology. 12 (2), 160–174.
Okamura, H., Watanabe, T., Narabayashi, M., Katsumata, N., Ando, M., Adachi, I., et al.
(2000) Psychological distress following first recurrence of disease in patients with
breast cancer: prevalence and risk factors. Breast Cancer Research and Treatment. 61
(2), 131–137.
Olfson, M., Marcus, S.C., Pincus, H.A., Zito, J.M., Thompson, J.W. & Zarin, D.A. (1998)
Antidepressant Prescribing Practices of Outpatient Psychiatrists. Archives of General
Psychiatry. 55 (4), 310–6.
Oxman, T.E., Barrett, J.E., Freeman, D.H. & Manheimer, E. (1994) Frequency and correlates
of adjustment disorder related to cardiac surgery in older patients. Psychosomatics. 35
(6), 557–568.
Patra, B.N. & Sarkar, S. (2013) Adjustment disorder: current diagnostic status. Indian
Journal of Psychological Medicine. 35 (1), 4–9.
Paykel, E.S., Prusoff, B.A. & Uhlenhuth, E.H. (1971) Scaling of life events. Archives of
General Psychiatry. 25 (4), 340–347.
Pelkonen, M., Marttunen, M., Henriksson, M. & Lönnqvist, J. (2007) Adolescent adjustment
disorder: precipitant stressors and distress symptoms of 89 outpatients. European
Psychiatry. 22 (5), 288–295.
Selye, H. (1973) The evolution of the stress concept. American Scientist. 61 (6), 692–699.
Snow, R. (2017) Bereavement without a death. BMJ. 3571–2.
Strain, J.J., Smith, G.C., Hammer, J.S., McKenzie, D.P., Blumenfield, M., Muskin, P., et al.
(1998) Adjustment disorder: a multisite study of its utilization and interventions in the
consultation-liaison psychiatry setting. General Hospital Psychiatry. 20 (3), 139–149.
Varker, T., Brand, R.M., Ward, J., Terhaag, S. & Phelps, A. (2019) Efficacy of synchronous
telepsychology interventions for people with anxiety, depression, posttraumatic
stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological
Services. 16 (4), 621–635.
Woelk, H., Arnoldt, K.H., Kieser, M. & Hoerr, R. (2007) Ginkgo biloba special extract
EGb 761 in generalized anxiety disorder and adjustment disorder with anxious mood:
a randomized, double-blind, placebo-controlled trial. Journal of Psychiatric Research.
41 (6), 472–480.
World Health Organisation (1992) International Statistical Classification of Diseases.
Geneva:
Yaseen, Y.A. (2017) Adjustment disorder: Prevalence, sociodemographic risk factors, and
its subtypes in outpatient psychiatric clinic. Asian Journal of Psychiatry, 28, 82–85.

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